Open Access

Original Article

Management of thoracic trauma in emergency

service: Analysis of 1139 cases
Isa Dongel1, Abuzer Coskun2, Sedat Ozbay3,
Mehmet Bayram4, Bahri Atli5
ABSTRACT
Objective: Thoracic trauma is a common cause of significant morbidity and mortality. This study presents
a series of thoracic trauma with the aim to assess epidemiologic features, distribution of pathologies,
additional systemic injuries, diagnosis, management and outcome.
Methodology: Between January 2007 and December 2011, all patients with thorax trauma admitted to the
emergency service of our hospital were retrospectively reviewed with respect to age, gender, etiological
factors, distribution of pathologies, additional systemic injuries, diagnosis, treatment modalities, referral
and outcome.
Results: A total of 1139 patients with thorax trauma were included in the study. Of these, 698 (61.3%) were
male and 441 (38.7%) were female, and the average age was 54.17±17.39 years. 1090 (95.7%) of the patients
had blunt trauma, whereas 49 (4.3%) had penetrating trauma. Etiological factors were falls in 792 (69.5%),
motor vehicle accidents in 259 (22.8%), animal related accidents in 39 (3.4%) and penetrating injuries in 49
(4.2%) patients. It was found that 229 (20%) patients had single, 101 (8.9%) had double, 5 (3%) had three or
more, 10 (0.9%) had bilateral rib fractures and 19 (1.7%) had sternal fracture. Pneumothorax was diagnosed
in 58 (5.1%) patients, whereas hemothorax, hemopneuomothorax and other system injuries were diagnosed
in 36 (3.2%), 38(3.3%) and 292 (25.6%) respectively. In our series, thirteen patients (mortality rate 1.1%)
died as result of hemorrhagic shock (n=8), respiratory distress (n=3) and severe multiple trauma (n=2).
Conclusion: Although majority of the patients with thorax trauma receive treatment as outpatients; thoracic
traumas may be a life threatening condition, and should be identified and treated immediately. Mortality
varies based on etiological factors, additional systemic pathologies, capabilities of the hospital especially
diagnostic and treatment facilities in emergency services. We believe that a multidisciplinary approach
to the patients with severe thorax trauma, and the opportunities of emergency bedside thoracotomy in
emergency services will significantly reduce the morbidity and mortality.
KEY WORDS: Thoracic trauma, Hemothorax, Pneumothorax, Rib fractures, Mortality.

doi: http://dx.doi.org/10.12669/pjms.291.2704
How to cite this:
Dongel I, Coskun A, Ozbay S, Bayram M, Atli B. Management of thoracic trauma in emergency service: Analysis of 1139 cases. Pak J
Med Sci 2013;29(1):58-63. doi: http://dx.doi.org/10.12669/pjms.291.2704
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Correspondence: INTRODUCTION
Isa Dongel, Mortality due to trauma rank third after
Department of Thoracic Surgery, cardiovascular diseases and cancers among the
Suleyman Demirel University,
Isparta, Turkey, causes of adult death worldwide. Thoracic trauma
E-mail: drdongel@hotmail.com constitutes 20-25% of all death due to trauma in
the first four decades.1 As esophagus, trachea,
* Received for Publication: July 18, 2012
* Revision Received: December 5, 2012
heart, diaphragm and large vessels can be injured
* Revision Accepted: December 12, 2012 along with chest cage and lungs in thoracic trauma,
it may be a life-threatening condition in some

58 Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk

 Thoracic Trauma

Table-I: Etiological reasons in thoracic traumas. Table-II: Distribution of thoracic traumas according
N % to seasons and years.
Years Spring Summer Autumn Winter TOTAL
Blunt Low impact fall 522 45.8
N (%) N (%) N (%) N (%)
thoracic (while walking, stairs, etc.)
traumas High impact fall 270 23.7 2007 37 (17.9) 27 (13.0) 80 (38.6) 63 (30.4) 207 (100)
(2 m and above) 2008 47 (24.0) 58 (29.6) 47 (24.0) 44 (22.4) 196 (100)
Accident inside vehicle 94 8.3 2009 86 (33.5) 57 (22.2) 42 (16.3) 72 (28.0) 257 (100)
Accident outside vehicle 165 14.5 2010 72 (27.3) 77 (29.2) 56 (21.2) 59 (22.3) 264 (100)
Animal accident 39 3.4
2011 59 (27.4) 71 (33.0) 59 (27.4) 26 (12.1) 215 (100)
Penetrating Stabbing injuries 32 2.8
thoracic Firearm injuries 17 1.4 TOTAL 301 290 284 264 1139
traumas (26.4) (25.5) (24.9) (23.2) (100)
TOTAL 1139 100 hospitalized at thoracic surgery clinic, and others
cases. Thus, we planned retrospective clinical
2 who were hospitalized at other clinics due to
study of patients with thorax trauma with the aim additional pathologies were followed up closely.
to assess epidemiologic features, distribution of RESULTS
pathologies, additional systemic injuries, diagnosis,
management and outcome. A total of 1139 patients with thorax trauma
were included in the study. Of all the patients, 698
METHODOLOGY (61.3%) were male and 441 (38.7%) were female.
Records of all patients with thorax trauma The majority of the patients presented with blunt
admitted to the emergency service of Sivas thoracic trauma (1090 of 1139 [95.7%]), whereas 49
Numune Hospital between January 2007 and (4.3%) presented with penetrating injuries. Etio-
December 2011 were retrospectively reviewed in logical factors included falls in 792 (69.5%) patients,
terms of age, gender, distribution by seasons and motor vehicle accidents in 259 (22.8%), animal re-
years, pathologies in thorax, rates of emergent lated accidents in 39 (3.4%) and penetrating injuries
tube thoracostomy, additional systemic injuries, in 49 (4.2%). Among penetrating injuries, 32 (2.8%)
hospitalization time, referral to tertiary centres, and were stabbing injuries and 17 (1.4%) were firearm
mortality rates. Pediatric patients under 16 years of injuries (Table-I). Distribution of the thoracic trau-
age were excluded. After admission, all the patients mas by seasons and years were similar (Table-II).
were evaluated by baseline physical examination, The patients were aged between 16 and 89 (mean
plain radiography, electrocardiography and blood 54.17±17.39) years. The vast majority (70.2%) of the
tests. Ultrasonography and computed tomography patients were aged between 31 and 70 years. Blunt
of thorax were used in some cases when necessary. thoracic traumas were observed most frequently
Tube thoracostomy was performed in all patients in patients aged 51-70 years (37%), whereas pen-
with pneumothorax or hemopneumothorax by a etrating traumas were observed most frequently in
thoracic surgeon either at the emergency service or those aged 31-50 (33,2%) years (Table-III).
thoracic surgery clinic. The patients were evaluated In term of thoracic pathologies; rib and sternum
in terms of coexisting pathologies by the concerned fractures, pneumothorax, hemopneumothorax, and
traumatology physicians at the emergency service. coexisting injuries were observed in the patients.
Most of the patients with thorax trauma were Seven hundred fifty five (66.2%) patients had no

Table-III: Distribution of thoracic traumas according to age range.

N 16-30 years(%) 31-50 years(%) 51-70 years(%) >70 years(%)
Low impact fall 522 45 (8.6) 172 (33.0) 196 (37.5) 109 (20.9)
High impact fall 270 21 (7.8) 95 (35.2) 100 (37.0) 54 (20.0)
Accident inside vehicle 94 9 (9.6) 32 (34.0) 39 (41.5) 14 (14.9)
Accident outside vehicle 165 15 (9.1) 45 (27.3) 65 (39.4) 40 (24.2)
Animal accident 39 1 (2.6) 9 (23.1) 14 (35.9) 15 (38.5)
Stabbing injuries 32 10 (31.3) 16 (50.0) 6 (18.6) -
Firearm injuries 17 4 (23.5) 9 (52.9) 1 (5.9) 3 (17.6)
TOTAL 1139 105 (9.2) 378 (33.2) 421 (37.0) 235 (20.6)

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Isa Dongel et al.

Table-IV: Rib and sterna fractures.

No Fracture(%) 1 fracture 1-3 fracture ≥3 fracture Bilateral Sternal
fracture fracture
Right Left Right Left Right Left
Blunt Low impact fall 471 (90) 19 21 6 5 - - - -
thoracic High impact fall 118 (43) 42 46 15 25 9 6 3 6
traumas Accident inside vehicle 15 (15) 23 19 6 9 4 7 2 9
Accident outside vehicle 103 (62) 17 21 10 12 3 2 3 4
Animal accident 8 (20) 6 7 5 7 1 3 2 -
Penetrating Stabbing injuries 26 (81) 2 3 1 - - - - -
thoracic Firearm injuries 14 (82) 2 1 - - - - - -
traumas
TOTAL 755 111 118 43 58 17 18 10 19
(66.2) (9.7) (10.3) (3.7) (5.0) (1.4) (1.5) (0.8) (1.6)

fracture, whereas sternal fractures were diagnosed injury in 52 (4.6%), abdominal injury in 95 (8.3%),
in 19 (1.7%), and one or more rib fractures were di- and muscoskeletal injury in 145 (12.7%). The vast
agnosed in 375 (33.0%), in which 20.1% (n=229) had majority of these were related with blunt traumas
single, 8.9% (n=101) had two, 3.1% (n=35) had three (Table-V).
or more, 0.9% (n=10) had bilateral rib fractures. In Outpatient treatment, referral, hospitalization and
single rib fractures, fracture was right sided in 111 mortality rates are shown in Table-VI. 688 (60.4%)
(0.9%) and left sided in 118 (10.3%). In 2 rib frac- of the cases were treated as outpatients, while 419
tures, fractures were right sided in 43 (3.8%) and (36.8%) patients were hospitalized for treatment.
left sided in 58 (5.1%). In rib fractures more than 3, The average length of hospitalization was 6,7
fractures were right sided in 17 (1.5%) and left sided days. Emergency thoracotomy was performed in 9
in 18 (1.6%) (Table-IV). Pneumothorax was diag- patients with penetrating injury at operating room.
nosed in 58 (5.1%) patients (23 right sided, 34 left Of these; 4 patients who had severe intercostal
sided and 1 bilateral). Hemothorax was diagnosed artery bleeding, pulmonary and diaphragm injuries
in 36 (3.2%) patients (15 right sided, 16 left sided were operated successfully, unfortunately 5 died
and 5 bilateral), and hemopneumothorax was diag- duo to major vascular and cardiac injuries during
nosed in 38 (3.3%) patients (15 right sided, 17 left surgery. Nineteen patients (1.7%) were referred to
sided and 6 bilateral). Pneumothorax was observed a tertiary centre because of deterioration in general
more frequent in blunt traumas, whereas hemotho- condition and coexisting pathologies, including
rax and hemopneumothorax were observed more spinal injury due to vertebral fracture (n=5),
frequent in penetrating traumas. Coexisting injuries subdural haemorrhage and cerebral contusion
were detected in 292 (25.6%) of the patients; brain (n=4), hemorrhagic shock due to laceration of liver
Table-V: Pneumothorax, hemothorax, hemopneumothorax due to thoracic traumas and accompanying injuries.
Pneumothorax Hemothorax Hemopneumothorax Brain Abdominal Musco-
skeletal
Right Left Bilateral Right Left Bilateral Right Left Bilateral
Blunt Low impact fall 1 - - - - - - - - 4 7 12
thoracic High impact fall 4 6 - 2 3 2 2 3 1 16 27 64
traumas Accident inside 8 12 1 2 1 1 - - 1 19 23 24
vehicle
Accident outside 3 2 - - 1 - 1 1 - 7 11 13
vehicle
Animal accident 2 7 - 2 2 1 1 2 1 1 9 11
Penetrating Stabbing injuries 3 6 - 6 7 1 6 4 1 3 13 12
thoracic Firearm injuries 2 1 - 3 2 - 5 7 2 2 5 9
traumas
TOTAL 23 34 1 15 16 5 15 17 6 52 95 145
# Tube thoracostomy was performed in all the patients undergoing pneumothorax or hemopneumothorax due to traumatologic reasons.

60 Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk


Table-VI: Outpatient treatment, referral, hospitalization and mortality rates in thoracic traumas.
Outpatient treatment (%)
Low impact fall 449 (86.0)
High impact fall 130 (48.4)
Accident inside vehicle 24 (25.5)
Accident outside vehicle 72 (43.9)
Animal accident 11 (28.2)
Stabbing injuries 2 (6.3)
Firearm injuries ––––
TOTAL 688 (60.4)
and/or spleen (n=3), requirement for dialysis due
to CRASH syndrome (n=1), respiratory failure
(n=2), hemorrhagic shock due to cardiac and main
vascular injuries (n=4). In our case series, mortality
rate was 1.1% (n=13). Cause of mortality were
hemorrhagic shock (n=8), respiratory failure (n=3),
cardiac contusion (n=1) and respiratory arrest due
to dislocation of upper cervical vertebra (n=1). All
of these were intubated in emergency service, and
cardiopulmonary resuscitation was performed.
Blood transfusion was also carried out in patients
in hemorrhagic shock.
DISCUSSION
Thoracic injuries mostly occur as a component
of multiple traumas. Early diagnosis and
treatment is life-saving for acutely injured
patients. The management principles are simple
and straightforward. The best management
for these patients includes early mobilization,
aggressive pain control, proper fluid management,
and respiratory physiotherapy. Endotracheal
intubation should be reserved for the patients with
airway compromise, refractory problems with gas
exchange, hypoventilation, and decreased mental
status. Prophylactic intubation is not a desired
measure for severe chest wall injury.3 The elderly
patients carry the greatest risk for pneumonia,
respiratory failure, and multiple organ failure.
Special efforts at aggressive regional pain control
are probably beneficial in this group of high risk
patients.4
The most complications in these patients
include respiratory failure due to altered chest
wall mechanics from the fractures and respiratory
distress from fracture-associated pain. Underlying
pulmonary contusion plays a prominent role in
the hypoxia that develops after chest wall injury.
This complex pathophysiology often necessitates
endotracheal intubation, prolonged mechanical
ventilation, tracheostomy, and prolonged intensive
care unit length of stay.5 In addition, poor pulmonary
Thoracic Trauma
Hospitalization (%) Referral (%) Mortality(%)
72 (13.8) 1 (0.2) ––
136 (50.5) 3 (0.01) 1 (0.003)
63 (67) 4 (4.3) 3 (3.2)
89 (54) 3 (0.02) 1 (0.01)
25 (64.1) 2 (5.1) 1 (2.6)
23 (71.8) 4 (12.5) 3 (9.4)
11 (64.7) 2 (11.8) 4 (23.5)
419 (36.8) 19(1.7) 13 (1.1)
function and mechanical ventilation increase the
risk for the development of pneumonia, which is
a frequent cause of death.6 Several factors such as
age, the total number of fractures, and the presence
of bilateral fractures have been shown to contribute
to the morbidity and mortality associated with
thoracic wall injury.
Thoracic trauma constitutes majority of the
trauma cases in emergency clinics. One third of
the hospitalizations for trauma consist of thoracic
injuries. In this respect, the results of the present
study are similar with the literature. The frequencies
of blunt trauma and penetrating injuries have been
reported as 58-75% and 24-41% respectively.1,2
Another study from Canada reported frequency of
blunt thoracic trauma as 96.3%.7 In our study, 95.7%
of the patients had blunt and 4.3% had penetrating
thoracic trauma, which was similar to the results
obtained in the Canadian study. We believe that
different results are associated with different socio-
economical status, developmental levels and
opportunities in emergency clinics. Low ratio of
penetrating injury in our study may be related to
the facts that some of the patients with penetrating
injury were taken to a third level hospital or some
lost their lives before taken to a hospital. Distribution
of the thoracic traumas by seasons and years were
similar in our study. The vast majority (70.2%) of the
patients were aged between 31 and 70 years. Blunt
thoracic traumas were observed most frequently
in patients aged 51-70 years, whereas penetrating
traumas were observed most frequently in those
aged 31-50 years. Motor vehicle accidents and falls
are the most frequently observed etiological factors
in thoracic traumas.8 Motor vehicle accidents have
been reported as the most common etiological factor
with a frequency between 42% and 80.2% in large
series.9,10 In our study, falls were the most frequent
etiological factor with a ratio of 69.5%, and falls
were followed by motor vehicle accidents (26.2%).
We believe that different ratios in our study were
caused by the fact that the study region has a cold
Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk 61
Isa Dongel et al.
climate, thus falls while walking or from height
were observed frequently due to snow and ice.
Postero-anterior lung X-ray is the most valuable
diagnosis method in thoracic traumas. Routine
postero-anterior lung X-ray is sufficient to diagnose
rib fractures, pneumothorax, hemothorax and lung
contusions. Trupka et al.11 reported that computed
tomography is superior to posterior-anterior lung
X-rays in imaging contusion, pneumothorax and
hemothorax screening in blunt thoracic trauma and
that it should be the first method to be used in those
having multiple injuries and suspected to have
thoracic trauma. We believe that postero-anterior
X-ray should be performed in patients having
thoracic trauma and computed tomography should
be used if further examination is needed.
Clinical features in thoracic trauma varies
from a simple soft tissue injury to a life-
threatening condition. Pnemothorax, hemothorax,
hemopneumothorax, pulmonary contusion and
rib fractures are the most frequently observed
findings. Fractures occur frequently due to blunt
thoracic traumas.1,2 In our study, one or more rib
fractures were diagnosed in 33.0% of the patients,
and almost all of the rib fractures occurred due to
blunt thoracic trauma. Sternal fracture is observed
in 3-8% of the cases with blunt thoracic trauma12,
whereas 1.7% of the patients had sternal fracture
in the present study. It is known that 18-62% of
sternal fractures are accompanied with cardiac
injury.13 We think that one of the reasons of sudden
deaths at early stage is cardiac contusion, as one
of the patient died due to cardiac contusion in our
series. Therefore, electrocardiography and cardiac
enzyme panel was carried out in all the patients
suspected to have sternal fracture. The most
frequently observed intrathoracic pathologies in
thoracic trauma are pneumothorax, hemothorax
or both, and the first stage of treatment is tube
thoracostomy.14,15 In our study, pneumothorax was
diagnosed in 5.1% of patients, whereas hemothorax
and hemopneumothorax were diagnosed in 3.1%
and 3.3% respectively. All of these patients were
subjectedtotubethoracotomy.Therearepublications
reporting that life-threatening complications such
as tension pneumothorax could be prevented
by this way.15 On the other hand, Menger et al.16
reported the ratio of tube complications as 20%.
We advocate that chest tube should be inserted
in all pneumothorax and hemopneumothorax
cases by experienced physicians. In our study,
0.8% (n=9) of the patients underwent emergency
thoracotomy. The indications were hemorrhagic
62 Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk
shock, and hemorrhagic drainage greater than 1500
cc following tube insertion, or bleeding >100 cc/hr
within 6-8 hours, or >200 cc/hr within 3-4 hours.
The most important factors affecting mortality
in thoracic trauma is coexisting injuries in other
systems and organs. In a study including 3406
cases, Regel et al.17 reported that thoracic traumas
were most frequently accompanied by extremity
fractures and this is followed by brain injuries.
In similar studies, thoracic traumas have been
reported to be accompanied most frequently by
musculoskeletal injuries.1,10,18 In our study, 25.6%
of the patients had coexisting systemic injuries,
in which the musculoskeletal injuries were the
most frequently observed one. In thoracic trauma,
physicians in emergency service should be alert for
coexisting systemic injuries.
In our study, 60.4% of the cases admitted to the
emergency service were treated as outpatients, and
36.8% were hospitalized for treatment. About 1.7%
of the patients were referred to a tertiary level centre
because of coexisting systemic pathologies and
deterioration in their general condition. Emircan et
al.19 studied factors affecting mortality of patients
with thoracic trauma, and reported that Trauma
Revised Score-Injury Severity Score has been the
strongest factor in determining mortality and thus
patients with thoracic trauma should be treated as a
high risk group and diagnosis and treatment should
be aggressive. Although our approach towards
the patients with thoracic trauma was aggressive
too, early stage mortality was observed in 1.1%
of the patients. In some studies, mortality rates
have been found to be increased in patients aged
45 and less, and 65 and over. Mortality rates have
been found to be significantly higher in penetrating
injuries and traffic related injuries to pedestrians
when compared to other injuries. Akcam et al.20
performed emergency bedside thoracotomy in 6
patients with penetrating injury and 3 patients
with blunt thoracic trauma, and success was
only achieved in 3 patients with penetrating
injury. They concluded that emergency bedside
thoracotomy is a life-saving procedure in the cases
of penetrating thoracic injury. As we had no facility
of emergency bedside thoracotomy in emergency
services, thoracotomies were compulsorily
performed in operating room. We lost minutes,
which is important for the patients. Emergency
thoracotomy was performed in 9 patients with
penetrating injury. Of these, 4 were operated
successfully. Unfortunately, 5 patients died due
to major vascular and cardiac injuries during

the operation. We think that emergency bedside
thoracotomy may be a life-saving procedure in
these patients.
In conclusion, although some of the patients with
thorax trauma receive treatment as outpatients;
thoracic traumas may be a life threatening
condition, and should be identified and treated
immediately. Mortality varies based on etiological
factors, additional systemic pathologies, capabilities
of the hospital especially diagnostic and treatment
facilities in emergency services. We believe that a
multidisciplinary approach to the patients with
severe thorax trauma, and the opportunity of
emergency bedside thoracotomy in emergency
services will significantly reduce the morbidity and
mortality.
REFERENCES
1. Altunkaya A, Aktunc E, Kutluk AC, Buyukates M, Demircan
N, Demir AS, et al. Analysis of 282 patients with thoracic
trauma. Turk J Thorac Cardiovasc Surg. 2007;15:127-132.
2. Graeber GM, Prabhakar G, Shields T. Blunt and penetrating
injuries of the chest wall, pleura and lungs. In: Shields
TW, LoCicero J 3rd, Ponn RB, Rusch VW editors. General
thoracic surgery. 6th ed. Philadelphia: Lippincott Williams
& Wilkins; 2005:951-972.
3. Bolliger CT, Van Eeden SF. Treatment of multiple rib
fractures. Randomized controlled trial comparing
ventilatory with nonventilatory management. Chest.
1990;97:943-948.
4. Todd SR, McNally MM, Holcomb JB, Kozar RA, Kao LS,
Gonzalez EA, et al. A multidisciplinary clinical pathway
decreases rib fracture-associated infectious morbidity
and mortality in high-risk trauma patients. Am J Surg.
2006;192:806-811.
5. Flagel BT, Luchette FA, Reed RL, Esposito TJ, Davis KA,
Santaniello JM, et al. Half-a-dozen ribs: the breakpoint for
mortality. Surg. 2005;138:717–723.
6. Brasel KJ, Guse CE, Layde P, Weigelt JA. Rib fractures:
relationship with pneumonia and mortality. Crit Care Med.
2006;34:1642–1646.
Thoracic Trauma
7. Hill AB, Fleiszer DM, Brown RA. Chest trauma in a
Canadian urban setting - implications for trauma research
in Canada. J Trauma. 1991;31:971-973.
8. Senturk E, Dogan Y, Yoldas E. Chest Trauma; Analysis of
1142 Cases. Turkish Thoracic J. 2010;11:47-54.
9. Cakan A, Yuncu G, Olgac G, Alar T, Sevinc S, Ors Kaya S.
Thoracic trauma: analysis of 987 cases. Turkish J Trauma
Emerg Surg. 2001;7:236-241.
10. Leblebici IH, Kaya Y, Kocak AH. Analysis of 302 cases
with chest trauma. Turkish J Thorac Cardiovasc Surg.
2005;13:392-396.
11. Trupka A, Waydhas C, Hallfeldt KK, Nast-Kolb D, Pfeifer
KJ, Schweiberer L. Value of thoracic computed tomography
in the first assessment of severely injured patients with
blunt chest trauma: results of a prospective study. J Trauma.
1997;43:405-411.
12. Brookes JG, Dunn RJ, Rogers IR. Sternal fractures: a
retrospective analysis of 272 cases. J Trauma. 1993;35:46-54.
13. Heyes FL, Vincent R. Sternal fractures: what investigations
are indicated? Injury. 1993;24:113-115.
14. Sirmali M, Turut H, Topcu S, Gulhan E, Yazici U, Kaya S,
et al. A comprehensive analysis of traumatic rib fractures:
morbidity, mortality and management. Eur J Cardiothorac
Surg. 2003;24:133-138.
15. Boyd AD. Pneumothorax and hemothorax. In: Hood
RM, Boyd AD, Culliford AT (eds): Thoracic trauma,
Philadelphia, 1989;133-148.
16. Menger R, Telford G, Kim P, Bergey MR, Foreman J, Sarani
B, et al. Complications following thoracic trauma managed
with tube thoracostomy. Injury. 2012;43:46-50.
17. Regel G, Lobenhoffer P, Grotz M, Pape HC, Lehmann U,
Tscherne H. Treatment results of patients with multiple
trauma: an analysis of 3406 cases treated between 1972
and 1991 at a German Level I Trauma Center. J Trauma.
1995;38:70-78.
18. Cagirici U, Uc H, Calkavur T, Gurcun U, Badak I, Bilkay O,
et al. Thoracic Trauma: The 6-Year Experience. Turkish J
Trauma Emerg Surg. 1998;4:248-252.
19. Emircan S, Ozguc H, Aydin SA, Ozdemir F, Koksal O,
Bulut M. Factors affecting mortality in patients with thorax
trauma. Turkish J Trauma Emerg Surg. 2011;17:329-333.
20. Akcam TI, Turhan K, Ergonul AG, Oguz E, Cakan A,
Cagirici U. A life-saving approach after thoracic trauma:
Emergency room thoracotomy. Turkish J Trauma Emerg
Surg. 2012;18:306-310.
Authors:
1. Isa Dongel,
Dept. of Thoracic Surgery,
Suleyman Demirel University, Isparta, Turkey.
2. Abuzer Coskun,
Dept. of Emergency, Cumhuriyet University, Sivas, Turkey.
3. Sedat Ozbay,
Dept. of Emergency, Sivas Numune Hospital, Sivas, Turkey.
4. Mehmet Bayram,
Dept. of Chest Disease,
Bezmialem Vakif University, Istanbul, Turkey.
5. Bahri Atli,
Dept. of Emergency, Karabuk State Hospital,
Karabuk, Turkey.
Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk 63